Accident/Incident Report "*" indicates required fields LIFT DISABILITY NETWORK 611 Business Park Blvd., Suite 105 Winter Garden, FL 34777 407.228.8343Name* First Last Name of person injured/involvedEmail* Mobile PhoneDate of Birth MM slash DD slash YYYY Gender Male Female Were there any witnesses? Yes No Name of witness #1 First Last Phone of Witness #1Name of witness #2 First Last Phone of Witness #2Type of injury/situation List any others injured or involved Details of incidentlist out all details of the incident to the best of your ability.Action TakenInjury requires physician/hospital visit? Yes No If so, where or to whom were they taken? Lead Staff has been notified I will inform them immediatelyWere Parents/Guardian Notified? Yes No Signature of reporting party First Name Last Name Date MM slash DD slash YYYY Δ Accident/Incident Report "*" indicates required fields LIFT DISABILITY NETWORK 611 Business Park Blvd., Suite 105 Winter Garden, FL 34777 407.228.8343Name* First Last Name of person injured/involvedEmail* Mobile PhoneDate of Birth MM slash DD slash YYYY Gender Male Female Were there any witnesses? Yes No Name of witness #1 First Last Phone of Witness #1Name of witness #2 First Last Phone of Witness #2Type of injury/situation List any others injured or involved Details of incidentlist out all details of the incident to the best of your ability.Action TakenInjury requires physician/hospital visit? Yes No If so, where or to whom were they taken? Lead Staff has been notified I will inform them immediatelyWere Parents/Guardian Notified? Yes No Signature of reporting party First Name Last Name Date MM slash DD slash YYYY Δ
